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Treatment of duodenal ulcer in a small metropolitan community hospital
Treatment
of Duodenal
Metropolitan
Ulcer in a Small
Community
Hospital
DANIEL F. CASTEN, M.D., ARTHUR LARKIN, M.D., AND FRANCISCOG. QUIROGA,M.D., New York, New York
From the Department of‘ Surgery, h’ew York, New York.
Sydenknm
trostomy. Fifty-five patients were treated between January 1958 and February 1963 and fifty-two patients from February 1963 to the time of this writing. A comparison will be made of the immediate results of these two operative procedures and the indication for surgical treatment will be listed. In all patients, except some with perforation or massive bleeding, the diagnosis of duodenal ulcer had been confirmed on several occasions by gastrointestinal roentgenographic studies. Gastric acid studies by the twelve hour basal night secretion technic were employed in many patients, and in the remainder a typical histamine gastric analysis was carried out. The two groups were almost identical in composition as related to age, sex, and economic status.
Hospital,
VAILABLETODAYfor the surgical treatment of the complications of duodenal ulcer is a spectrum of basic procedures ranging from gastrojejunostomy or modified gastrojejunostomy as recently revived by Poth and Gold [1] to classical gastric resection. It appears increasingly evident that the addition of vagus neurectomy to these standard procedures for duodenal ulcer has lowered the recurrence rate appreciably, and the feasibility and success of pyloroplasty and vagus resection have been established in many centers. Recurrence rates after gastric resection and vagus neurectomy are satisfactory; however, in many series the mortality associated with gastric resection, due principally to difficulties with the duodenal stump, is higher than one should tolerate in the surgical treatment of a benign disease. The present study details the results of the surgical treatment of duodenal ulcer in a small metropolitan community hospital. The surgical staff participating in this study consists of trained surgeons, all either Fellows of the American College of Surgeons, Diplomates of the American Board of Surgery, or qualified by training for the examination of the American Board of Surgery. A retrospective study of the hospital course, mortality, and morbidity of operations for duodenal ulcer is herein presented. From January 1958 to February 1963 gastric resection was employed for the complications of duodenal ulcer in all patients. Since February 1, 1963, all patients with duodenal ulcer treated surgically have been subjected to vagus resection, pyloroplasty with or without plication of the ulcer, and gas-
A
Vol. 11.3. Much
1967
PARTIALGASTRICRESECTIoN In fifty-five patients, partial gastric resection was employed. Of these, thirty-one patients were ward patients and twenty-four were private patients. There were thirty-six male and nineteen female patients; the youngest was nineteen years of age and the oldest seventy years, the average age being forty-four. Duration of symptoms referable to the ulcer varied from one day (perforation) to twenty years. Thirty-five patients had received an adequate medical therapeutic regimen, nine had only inconstant medical treatment, and the remaining eleven had had no previous medical treatment, In these, bleeding and perforation were the indications for operative procedures, and therefore no prolonged preoperative therapy had been employed. The indications for surgical intervention in this group were intractability in twenty-two patients (nine ward and thirteen private), bleed335
336
Casten, Larkin, and Quiroga
ing in twenty-five patients (nineteen ward and six private), of whom fourteen had massive bleeding, pyloric obstruction in three patients, and perforation in five. A high percentage of patients with bleeding was encountered in this series because customarily in this hospital surgical therapy for duodenal ulcer was not recommended until serious complications ensued. In all but one patient in this series, gastric resection with some modification of the Billroth II procedure was performed. In the majority of these patients an antecolic antiperistaltic anastomosis was made; in forty-one patients, an antiperistaltic anastomosis; and in thirty-three, an antecolic anastomosis. One patient had gastroduodenal reconstruction employing a Billroth I procedure. A Polya reconstruction was favored but occasionally either a Hofmeister-Finsterer retrocolic anastomosis or a Von Eiselsberg antecolic anastomosis was performed. Six deaths occurred in the immediate postoperative period in this group of patients, a mortality of 10.9 per cent. Of these, four patients died of acute peritonitis, one of septicemia with liver abscess, and one of acute pancreatitis. All of these deaths were definitely related to the operative procedure and were the result of either the severity of the disease or the technical problems involved in gastric resection. There were, in addition, many nonfatal complications, including leakage of the duodenal stump in two patients, wound dehiscence in one, postoperative gastrointestinal bleeding in one, and thrombophlebitis in two. Again, all of these complications except thrombophlebitis and wound dehiscence were directly related to the nature of the surgical procedure. The average duration of hospitalization for the patients in this group was 25.5 days; for private patients it was 12.2 days and for ward patients 31.9 days. The prolonged period of hospitalization of the ward patients is related to the circumstances in this hospital wherein patients sometimes must wait a week to ten days or more before being scheduled for operation. While the mortality in this series as compared to other reported series was exceedingly high, an inordinately high percentage of patients was operated on for massive bleeding in this group. As is well known, operations for this indication are associated with a mortality
of 12 to 20 per cent, as several large series of cases have demonstrated. The group reported by Enquist and his associates [2] from Kings County Hospital had a 16 per cent mortality while in a group of similar cases from the Peter Bent Brigham Hospital reported by Brooks and Eraklis [3] the mortality was 21 per cent in patients with massive bleeding. Nevertheless, it is believed that the total mortality of 10.9 per cent is much too high. VAGUS
RESECTION,
PYLOROPLASTY,
AND GASTROSTOMY
In this group there were fifty-two patients of whom thirty-four were ward patients and eighteen were private patients. There were forty-two male and ten female patients; the ages ranged from twenty-four to eighty-four years, the average age being 42.7 years. The average duration of ulcer symptoms was 5.7 years; the briefest period was twelve hours and the longest thirty-two years. Fifteen patients were considered to have received adequate medical treatment, whereas twenty-six had inconstant medical therapy and eleven patients had none. The indications for operative intervention were intractability in thirty-three patients, (nineteen ward and fourteen private), obstruction in five patients, (four ward and one private), bleeding in ten patients (seven ward and three private), and perforation in four patients (four ward). Complete abdominal truncal vagus resection, pyloroplasty, and temporary gastrostomy were performed in all fifty-two patients in this group. In addition the ulcer was excised in nineteen patients and the ulcer bed was plicated in seven. In three patients, repair of an associated hiatal hernia was carried out. There was one postoperative death (1.9 per cent) which occurred in a seventy year old woman who had been operated on because of a bleeding ulcer. On the fourteenth postoperative day after having recovered uneventfully she died suddenly of a massive pulmonary embolus confirmed on postmortem examination. Her recovery had been uncomplicated and she was completely ambulatory at the time of her sudden death. There were few complications after this procedure and these included one minor wound infection, one postoperative gastric dilatation due to withdrawal of the gastrostomy tube too early, and pneumonia in four patients. Minor pulmonary infarction occurred in two patients American Journal of Surgery
Duodenal and atelectasis in two others. In all, pulmonary complications developed in eight patients. The duration of hospitalization averaged 22.8 days; the ward patients averaged 25.6 days and the private patients 22.8 days. Immediate results of the operation in the hospital were excellent, and this has continued to be so in the follow-up study of these patients. However, this is beyond the scope of the present discussion. COMMENTS
The comparison between the immediate results in terms of postoperative mortality and morbidity in the two groups is striking. Elective gastric resection resulted in a mortality approximately six times that of vagus resection and pyloroplasty. The single death in the later group was not related to the type of operation, as were most of the deaths in the group with gastrectomy, but was related to the necessity for major surgery in elderly patients. The deaths in the group with gastrectomy reflect accurately the hazards of this operation; while the number is high, nevertheless it is not inconsistent with other reported series. Morbidity was much lower in the group undergoing vagus resection and a drainage operation, and the complications in this group were potentially less lethal than those which occurred after gastric resection. The mortality for gastric resection apparently varies widely in hospitals throughout the country. This may be less than 1 per cent in some institutions where patients with chronic duodenal ulcer without the complication of bleeding and perforation are operated on [4] and may be in the range of 20 per cent when patients operated on for massive hemorrhage are considered separately. Of the many reported series of patients undergoing gastric resection there are several representative reports. Ross, Cahill, and Zollinger [5] in a consecutive series of 300 patients undergoing partial gastrectomy for duodenal ulcer in a community hospital reported nineteen deaths or a mortality of 6.3 per cent. Of the survivors twenty-nine or 10 per cent had major complications in the immediate postoperative period. This group included older patients as well as those operated on for bleeding. Paine [6] reported an over-all hospital mortality of 5.7 per cent in a group of 684 patients with benign peptic ulcer treated by partial gastric resection; major postoperative complications occurred in almost one third Vol. 11.3. March
1967
Ulcer
:3:37
the patients. Paine [6] summarized eight other reported series detailing the results of gastric resection for duodenal ulcer, all of which were reported between 1954 and 1960. The average mortality in this group was 3.2 per cent. The survey by Hoerr et al. [7] is of great interest. They presented a state-wide survey of twenty-nine hospitals in Ohio with an average bed capacity range from 142 to 842 patients. The report dealt exclusively with the mortality after surgery for chronic duodenal ulcer, excluding patients with gastric and gastrojejunal ulcers. There were 432 surgeons taking part in this survey, of whom 23 per cent were not Board-certified nor Fellows of the American College of Surgeons. There were 2,562 elective procedures performed. Eighty per cent of these patients had 50 to 75 per cent resection of the stomach. Twenty per cent of the patients had vagus resection with an emptying procedure. Mortality in the group with gastric resection was 4.9 per cent whereas that in the group with vagus resection and drainage was l.i per cent. This group did not include patients with massive hemorrhage as the operations in this group were all elective procedures. Employing a method of arbitrary alternation of patients undergoing surgical procedure for duodenal ulcer, Hamilton and his associates [8] studied the results of vagus resection with an emptying procedure as contrasted to partial gastrectomy. They found that partial gastrectomy carried three times the mortality of vagus resection and drainage. They concluded that if vagus resection and drainage operations were selected over gastrectomy as the operation of choice among every 1,000 patients operated on for duodenal ulcer, there would be twenty more living patients. This is indeed a startling statistic. In a recent report from Canada, MacDonald and Welsh [9] also presented contrasting groups of patients, one group treated by subtotal gastric resection and the other by vagus resection and a drainage operation. The groups were roughly similar in composition, there being 173 in the former group and 170 in the latter group. There were thirty-nine serious postoperative complications and five deaths in the patients undergoing gastric resection, an overall mortality of 2.8 per cent; this is in contrast to the group undergoing vagus resection and pyloroplasty in which there were thirty-one postoperative complications and only two
Casten,
Larkin,
deaths, an over-all mortality of 1.2 per cent for all patients and a zero mortality for the elective ones. Both operative technics gave exceedingly good results but the contrast between the two groups is of considerable significance. In treatment of bleeding ulcer the results may be even more impressive. As noted previously, results of gastric resection for massive bleeding due to duodenal ulcer are poor indeed ; an overall mortality ranging from 12 to 20 per cent has been reported by various authors [2,3]. In contrast, Dorten [lo] has reported on 100 consecutive patients with duodenal ulcer in whom the indication for operation was active hemorrhage. In these patients, all treated by vagus resection and pyloroplasty, there were no deaths. Small and Ashraf [11 ] have reported a mortality of 3.6 per cent after vagus resection and a drainage operation in patients with massive bleeding as contrasted to 26.3 per cent in patients with gastric resection. Finally, the work of Weinberg [12] should be noted. In 1,022 patients undergoing vagus resection and pyloroplasty there were only seven deaths (0.7 per cent). Furthermore, Harbrecht and Hamilton [13] reported no deaths and no complications in a series of nineteen patients treated by vagus resection and pyloroplasty for acutely perforated duodenal ulcer. This minimal mortality was confirmed by Pierandozzi, Hinshaw, and Stafford 1141 who, in seventy-five patients operated on because of perforation, reported only one death (1.3 per cent). Holt and Lythgoe [15] and Burge [16] in England have confirmed the markedly diminished fatality rate resulting from vagus resection and a drainage operation. CONCLUSIONS
The immediate results of the treatment of duodenal ulcer in a small metropolitan community hospital are reported. Two similar groups are compared; the first, in which fiftyfive patients were submitted to gastric resection, is contrasted to the second group in which all patients were treated by vagus resection and pyloroplasty. The size of the group, indications for operation, and the operating surgeons are almost identical. The mortality in the former group is six times that in the latter group, and the nonfatal complications are equally significant. It is believed that the inherent difficulties in the management of the duodenal stump in patients undergoing gastrectomy account for
and Quiroga the disparity in the immediate results. Since cure rates in our experience as well as in many reports in the surgical literature are almost identical in two groups, there appears to be little valid reason for persisting in the use of a more difficult and dangerous operation when a simpler one is available. If long-term follow-up studies should belie the assumption of identical cure rates, it would still appear justifiable to employ vagus resection and pyloroplasty as the initial surgical procedure (with transfixion of bleeding vessels as indicated) and reserve gastric resection as a secondary operation in the few patients who present with recurrent ulcer. REFERENCES
1. POTH, E. J. and GOLD, D. Technics of gastrointestinal suture. Current Prob. Surg., 1: 46, 1965. 2. ENQUIST, I. F., KARLSON, K. E., DENNIS, C., FIERST. S. M.. and SHAFTAN. G. W. Gastroduodenal hemorrhage. Statistically valid ten-year comparative evaluation of three methods of management of massive gastroduodenal hemorrhage. Ann. Surg., 162: 550, 1965. 3. BROOKS, J. R. and ERAKLIS, A. J. Factors affecting the mortality from peptic ulcer: the bleeding ulcer and ulcer in the aged. New England J. Med., 271: 803, 1964. 4. BARTLETT, M. K. The surgical treatment for gastric ulcer. S. Clin. North America, 46: 319, 1966. 5. Ross, F. P., CAHILL, J. L., and ZOLLINGER, R. M., JR. Benign ulcer disease. Gastrectomy in a community hospital. Arch. Surg., 91: 443, 1965. 6. PAINE, 1. R. Immediate results of subtotal aastric resection for benign peptic ulcer. Surgery, 51: 561, 1962. 7. HOERR, S. O., et al. Elective operations performed for duodenal ulcer, with their mortality. Results of a survey in selected Ohio hospitals by the Survey Committee, Ohio Chapter, American College of Surgeons. Am. J. Surg., 96: 365, 1958. 8. HAMILTON, J. E., HARBRECHT, P. J., ROBBINS, R. E., and KINNAIRD, D. W. A comparative study of vagotomy and emptying procedure versus subtotal gastrectomy used alternately in the treatment of duodenal ulcer. Ann. Surg., 153: 934, 1961. 9. MACDONALD, J. A. and WELSH, W. K. The immediate results of operation for duodenal ulcer: a comparative study of the morbidity and mortality of vagotomy and pyloroplasty versus subtotal gastrectomy. Canad. M. A. J., 92: 652, 1965. 10. DORTEN, H. E. Vagotomy, pyloroplasty and suture: a safe and effective remedy for the duodenal ulcer that bleeds. A progress report on 100 consecutive cases. Ann. Surg., 153: 378, 1961. 11. SMALL, W. T. and ASHRAF, M. Pyloroplasty and vagotomy for duodenal ulcer: a review of a hundred and ten cases. New England J. Med., 272: 619, 1965. American Jouvnal of Surgery
Duodenal Ulcer 12 WEINBERG, J. A. Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Am. J. Surg., 105: 347, 1963. 13. HARBRECHT, P. J. and HAMILTON, J. E. Vagotomy aud emptying procedure in treatment of acute perforated duodenal ulcer. Arch. Surg., 85: 682, 196%. 14 PIEKANI)OZZI,J. S., HINSHAW, D. B., and STAFFORD,
Vol. 113, March
1967
C. E. I’agotomy and pyloroplasty for acute perforated duodenal ulcer. A report of seventy-five cases. Am. /. Surg., 100: 245, 1960. 15. HOLT, R. L. and LYTHGOE, J. P. ‘The treatment of chronic duodenal ulcer by vagotomy and anterior pylorectomy. &it. J. Surg., 52: 3;. 1965. 16. BURGE, H. Vagotomy. Baltimore, 1961. The Williams & Wilkins Co
of Duodenal
Metropolitan
Ulcer in a Small
Community
Hospital
DANIEL F. CASTEN, M.D., ARTHUR LARKIN, M.D., AND FRANCISCOG. QUIROGA,M.D., New York, New York
From the Department of‘ Surgery, h’ew York, New York.
Sydenknm
trostomy. Fifty-five patients were treated between January 1958 and February 1963 and fifty-two patients from February 1963 to the time of this writing. A comparison will be made of the immediate results of these two operative procedures and the indication for surgical treatment will be listed. In all patients, except some with perforation or massive bleeding, the diagnosis of duodenal ulcer had been confirmed on several occasions by gastrointestinal roentgenographic studies. Gastric acid studies by the twelve hour basal night secretion technic were employed in many patients, and in the remainder a typical histamine gastric analysis was carried out. The two groups were almost identical in composition as related to age, sex, and economic status.
Hospital,
VAILABLETODAYfor the surgical treatment of the complications of duodenal ulcer is a spectrum of basic procedures ranging from gastrojejunostomy or modified gastrojejunostomy as recently revived by Poth and Gold [1] to classical gastric resection. It appears increasingly evident that the addition of vagus neurectomy to these standard procedures for duodenal ulcer has lowered the recurrence rate appreciably, and the feasibility and success of pyloroplasty and vagus resection have been established in many centers. Recurrence rates after gastric resection and vagus neurectomy are satisfactory; however, in many series the mortality associated with gastric resection, due principally to difficulties with the duodenal stump, is higher than one should tolerate in the surgical treatment of a benign disease. The present study details the results of the surgical treatment of duodenal ulcer in a small metropolitan community hospital. The surgical staff participating in this study consists of trained surgeons, all either Fellows of the American College of Surgeons, Diplomates of the American Board of Surgery, or qualified by training for the examination of the American Board of Surgery. A retrospective study of the hospital course, mortality, and morbidity of operations for duodenal ulcer is herein presented. From January 1958 to February 1963 gastric resection was employed for the complications of duodenal ulcer in all patients. Since February 1, 1963, all patients with duodenal ulcer treated surgically have been subjected to vagus resection, pyloroplasty with or without plication of the ulcer, and gas-
A
Vol. 11.3. Much
1967
PARTIALGASTRICRESECTIoN In fifty-five patients, partial gastric resection was employed. Of these, thirty-one patients were ward patients and twenty-four were private patients. There were thirty-six male and nineteen female patients; the youngest was nineteen years of age and the oldest seventy years, the average age being forty-four. Duration of symptoms referable to the ulcer varied from one day (perforation) to twenty years. Thirty-five patients had received an adequate medical therapeutic regimen, nine had only inconstant medical treatment, and the remaining eleven had had no previous medical treatment, In these, bleeding and perforation were the indications for operative procedures, and therefore no prolonged preoperative therapy had been employed. The indications for surgical intervention in this group were intractability in twenty-two patients (nine ward and thirteen private), bleed335
336
Casten, Larkin, and Quiroga
ing in twenty-five patients (nineteen ward and six private), of whom fourteen had massive bleeding, pyloric obstruction in three patients, and perforation in five. A high percentage of patients with bleeding was encountered in this series because customarily in this hospital surgical therapy for duodenal ulcer was not recommended until serious complications ensued. In all but one patient in this series, gastric resection with some modification of the Billroth II procedure was performed. In the majority of these patients an antecolic antiperistaltic anastomosis was made; in forty-one patients, an antiperistaltic anastomosis; and in thirty-three, an antecolic anastomosis. One patient had gastroduodenal reconstruction employing a Billroth I procedure. A Polya reconstruction was favored but occasionally either a Hofmeister-Finsterer retrocolic anastomosis or a Von Eiselsberg antecolic anastomosis was performed. Six deaths occurred in the immediate postoperative period in this group of patients, a mortality of 10.9 per cent. Of these, four patients died of acute peritonitis, one of septicemia with liver abscess, and one of acute pancreatitis. All of these deaths were definitely related to the operative procedure and were the result of either the severity of the disease or the technical problems involved in gastric resection. There were, in addition, many nonfatal complications, including leakage of the duodenal stump in two patients, wound dehiscence in one, postoperative gastrointestinal bleeding in one, and thrombophlebitis in two. Again, all of these complications except thrombophlebitis and wound dehiscence were directly related to the nature of the surgical procedure. The average duration of hospitalization for the patients in this group was 25.5 days; for private patients it was 12.2 days and for ward patients 31.9 days. The prolonged period of hospitalization of the ward patients is related to the circumstances in this hospital wherein patients sometimes must wait a week to ten days or more before being scheduled for operation. While the mortality in this series as compared to other reported series was exceedingly high, an inordinately high percentage of patients was operated on for massive bleeding in this group. As is well known, operations for this indication are associated with a mortality
of 12 to 20 per cent, as several large series of cases have demonstrated. The group reported by Enquist and his associates [2] from Kings County Hospital had a 16 per cent mortality while in a group of similar cases from the Peter Bent Brigham Hospital reported by Brooks and Eraklis [3] the mortality was 21 per cent in patients with massive bleeding. Nevertheless, it is believed that the total mortality of 10.9 per cent is much too high. VAGUS
RESECTION,
PYLOROPLASTY,
AND GASTROSTOMY
In this group there were fifty-two patients of whom thirty-four were ward patients and eighteen were private patients. There were forty-two male and ten female patients; the ages ranged from twenty-four to eighty-four years, the average age being 42.7 years. The average duration of ulcer symptoms was 5.7 years; the briefest period was twelve hours and the longest thirty-two years. Fifteen patients were considered to have received adequate medical treatment, whereas twenty-six had inconstant medical therapy and eleven patients had none. The indications for operative intervention were intractability in thirty-three patients, (nineteen ward and fourteen private), obstruction in five patients, (four ward and one private), bleeding in ten patients (seven ward and three private), and perforation in four patients (four ward). Complete abdominal truncal vagus resection, pyloroplasty, and temporary gastrostomy were performed in all fifty-two patients in this group. In addition the ulcer was excised in nineteen patients and the ulcer bed was plicated in seven. In three patients, repair of an associated hiatal hernia was carried out. There was one postoperative death (1.9 per cent) which occurred in a seventy year old woman who had been operated on because of a bleeding ulcer. On the fourteenth postoperative day after having recovered uneventfully she died suddenly of a massive pulmonary embolus confirmed on postmortem examination. Her recovery had been uncomplicated and she was completely ambulatory at the time of her sudden death. There were few complications after this procedure and these included one minor wound infection, one postoperative gastric dilatation due to withdrawal of the gastrostomy tube too early, and pneumonia in four patients. Minor pulmonary infarction occurred in two patients American Journal of Surgery
Duodenal and atelectasis in two others. In all, pulmonary complications developed in eight patients. The duration of hospitalization averaged 22.8 days; the ward patients averaged 25.6 days and the private patients 22.8 days. Immediate results of the operation in the hospital were excellent, and this has continued to be so in the follow-up study of these patients. However, this is beyond the scope of the present discussion. COMMENTS
The comparison between the immediate results in terms of postoperative mortality and morbidity in the two groups is striking. Elective gastric resection resulted in a mortality approximately six times that of vagus resection and pyloroplasty. The single death in the later group was not related to the type of operation, as were most of the deaths in the group with gastrectomy, but was related to the necessity for major surgery in elderly patients. The deaths in the group with gastrectomy reflect accurately the hazards of this operation; while the number is high, nevertheless it is not inconsistent with other reported series. Morbidity was much lower in the group undergoing vagus resection and a drainage operation, and the complications in this group were potentially less lethal than those which occurred after gastric resection. The mortality for gastric resection apparently varies widely in hospitals throughout the country. This may be less than 1 per cent in some institutions where patients with chronic duodenal ulcer without the complication of bleeding and perforation are operated on [4] and may be in the range of 20 per cent when patients operated on for massive hemorrhage are considered separately. Of the many reported series of patients undergoing gastric resection there are several representative reports. Ross, Cahill, and Zollinger [5] in a consecutive series of 300 patients undergoing partial gastrectomy for duodenal ulcer in a community hospital reported nineteen deaths or a mortality of 6.3 per cent. Of the survivors twenty-nine or 10 per cent had major complications in the immediate postoperative period. This group included older patients as well as those operated on for bleeding. Paine [6] reported an over-all hospital mortality of 5.7 per cent in a group of 684 patients with benign peptic ulcer treated by partial gastric resection; major postoperative complications occurred in almost one third Vol. 11.3. March
1967
Ulcer
:3:37
the patients. Paine [6] summarized eight other reported series detailing the results of gastric resection for duodenal ulcer, all of which were reported between 1954 and 1960. The average mortality in this group was 3.2 per cent. The survey by Hoerr et al. [7] is of great interest. They presented a state-wide survey of twenty-nine hospitals in Ohio with an average bed capacity range from 142 to 842 patients. The report dealt exclusively with the mortality after surgery for chronic duodenal ulcer, excluding patients with gastric and gastrojejunal ulcers. There were 432 surgeons taking part in this survey, of whom 23 per cent were not Board-certified nor Fellows of the American College of Surgeons. There were 2,562 elective procedures performed. Eighty per cent of these patients had 50 to 75 per cent resection of the stomach. Twenty per cent of the patients had vagus resection with an emptying procedure. Mortality in the group with gastric resection was 4.9 per cent whereas that in the group with vagus resection and drainage was l.i per cent. This group did not include patients with massive hemorrhage as the operations in this group were all elective procedures. Employing a method of arbitrary alternation of patients undergoing surgical procedure for duodenal ulcer, Hamilton and his associates [8] studied the results of vagus resection with an emptying procedure as contrasted to partial gastrectomy. They found that partial gastrectomy carried three times the mortality of vagus resection and drainage. They concluded that if vagus resection and drainage operations were selected over gastrectomy as the operation of choice among every 1,000 patients operated on for duodenal ulcer, there would be twenty more living patients. This is indeed a startling statistic. In a recent report from Canada, MacDonald and Welsh [9] also presented contrasting groups of patients, one group treated by subtotal gastric resection and the other by vagus resection and a drainage operation. The groups were roughly similar in composition, there being 173 in the former group and 170 in the latter group. There were thirty-nine serious postoperative complications and five deaths in the patients undergoing gastric resection, an overall mortality of 2.8 per cent; this is in contrast to the group undergoing vagus resection and pyloroplasty in which there were thirty-one postoperative complications and only two
Casten,
Larkin,
deaths, an over-all mortality of 1.2 per cent for all patients and a zero mortality for the elective ones. Both operative technics gave exceedingly good results but the contrast between the two groups is of considerable significance. In treatment of bleeding ulcer the results may be even more impressive. As noted previously, results of gastric resection for massive bleeding due to duodenal ulcer are poor indeed ; an overall mortality ranging from 12 to 20 per cent has been reported by various authors [2,3]. In contrast, Dorten [lo] has reported on 100 consecutive patients with duodenal ulcer in whom the indication for operation was active hemorrhage. In these patients, all treated by vagus resection and pyloroplasty, there were no deaths. Small and Ashraf [11 ] have reported a mortality of 3.6 per cent after vagus resection and a drainage operation in patients with massive bleeding as contrasted to 26.3 per cent in patients with gastric resection. Finally, the work of Weinberg [12] should be noted. In 1,022 patients undergoing vagus resection and pyloroplasty there were only seven deaths (0.7 per cent). Furthermore, Harbrecht and Hamilton [13] reported no deaths and no complications in a series of nineteen patients treated by vagus resection and pyloroplasty for acutely perforated duodenal ulcer. This minimal mortality was confirmed by Pierandozzi, Hinshaw, and Stafford 1141 who, in seventy-five patients operated on because of perforation, reported only one death (1.3 per cent). Holt and Lythgoe [15] and Burge [16] in England have confirmed the markedly diminished fatality rate resulting from vagus resection and a drainage operation. CONCLUSIONS
The immediate results of the treatment of duodenal ulcer in a small metropolitan community hospital are reported. Two similar groups are compared; the first, in which fiftyfive patients were submitted to gastric resection, is contrasted to the second group in which all patients were treated by vagus resection and pyloroplasty. The size of the group, indications for operation, and the operating surgeons are almost identical. The mortality in the former group is six times that in the latter group, and the nonfatal complications are equally significant. It is believed that the inherent difficulties in the management of the duodenal stump in patients undergoing gastrectomy account for
and Quiroga the disparity in the immediate results. Since cure rates in our experience as well as in many reports in the surgical literature are almost identical in two groups, there appears to be little valid reason for persisting in the use of a more difficult and dangerous operation when a simpler one is available. If long-term follow-up studies should belie the assumption of identical cure rates, it would still appear justifiable to employ vagus resection and pyloroplasty as the initial surgical procedure (with transfixion of bleeding vessels as indicated) and reserve gastric resection as a secondary operation in the few patients who present with recurrent ulcer. REFERENCES
1. POTH, E. J. and GOLD, D. Technics of gastrointestinal suture. Current Prob. Surg., 1: 46, 1965. 2. ENQUIST, I. F., KARLSON, K. E., DENNIS, C., FIERST. S. M.. and SHAFTAN. G. W. Gastroduodenal hemorrhage. Statistically valid ten-year comparative evaluation of three methods of management of massive gastroduodenal hemorrhage. Ann. Surg., 162: 550, 1965. 3. BROOKS, J. R. and ERAKLIS, A. J. Factors affecting the mortality from peptic ulcer: the bleeding ulcer and ulcer in the aged. New England J. Med., 271: 803, 1964. 4. BARTLETT, M. K. The surgical treatment for gastric ulcer. S. Clin. North America, 46: 319, 1966. 5. Ross, F. P., CAHILL, J. L., and ZOLLINGER, R. M., JR. Benign ulcer disease. Gastrectomy in a community hospital. Arch. Surg., 91: 443, 1965. 6. PAINE, 1. R. Immediate results of subtotal aastric resection for benign peptic ulcer. Surgery, 51: 561, 1962. 7. HOERR, S. O., et al. Elective operations performed for duodenal ulcer, with their mortality. Results of a survey in selected Ohio hospitals by the Survey Committee, Ohio Chapter, American College of Surgeons. Am. J. Surg., 96: 365, 1958. 8. HAMILTON, J. E., HARBRECHT, P. J., ROBBINS, R. E., and KINNAIRD, D. W. A comparative study of vagotomy and emptying procedure versus subtotal gastrectomy used alternately in the treatment of duodenal ulcer. Ann. Surg., 153: 934, 1961. 9. MACDONALD, J. A. and WELSH, W. K. The immediate results of operation for duodenal ulcer: a comparative study of the morbidity and mortality of vagotomy and pyloroplasty versus subtotal gastrectomy. Canad. M. A. J., 92: 652, 1965. 10. DORTEN, H. E. Vagotomy, pyloroplasty and suture: a safe and effective remedy for the duodenal ulcer that bleeds. A progress report on 100 consecutive cases. Ann. Surg., 153: 378, 1961. 11. SMALL, W. T. and ASHRAF, M. Pyloroplasty and vagotomy for duodenal ulcer: a review of a hundred and ten cases. New England J. Med., 272: 619, 1965. American Jouvnal of Surgery
Duodenal Ulcer 12 WEINBERG, J. A. Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Am. J. Surg., 105: 347, 1963. 13. HARBRECHT, P. J. and HAMILTON, J. E. Vagotomy aud emptying procedure in treatment of acute perforated duodenal ulcer. Arch. Surg., 85: 682, 196%. 14 PIEKANI)OZZI,J. S., HINSHAW, D. B., and STAFFORD,
Vol. 113, March
1967
C. E. I’agotomy and pyloroplasty for acute perforated duodenal ulcer. A report of seventy-five cases. Am. /. Surg., 100: 245, 1960. 15. HOLT, R. L. and LYTHGOE, J. P. ‘The treatment of chronic duodenal ulcer by vagotomy and anterior pylorectomy. &it. J. Surg., 52: 3;. 1965. 16. BURGE, H. Vagotomy. Baltimore, 1961. The Williams & Wilkins Co